It looks like it's just a rhythm strip then a full 12 lead EKG. This is one of those times where someone that actually knew what they were talking about was writing the article to know how much information it really gives.

Seems like a way to bill a patient for something that really isn't worth a shiat. Without a 12 lead to give you the leads, you could potentially miss a heart attack without having corresponding leads to measure against, since the article seems to indicate it's just taking Lead I of a full 12 lead. If the doctor is truly looking for an arrhythmia, then I suppose this is a quick way to do it, but they're going to probably do a 12 lead if the app finds it. Would they double bill for this extremely limited ECG in addition to the 12 lead? It's a cool toy, sure, just not something I'd want to trust to a single lead for a determination of any potential heart conduction issues.

Yeah, but it's lead II vector monitoring. Which is only good for monitoring arrythmias. As Bob Paige says in his EKG seminars - Lead II no Clue.

In addition, beyond looking for the kind of arrythmias that you won't be able to look at your phone to see, it's a fun novelty but useless clinically.

If you need an ECG for an acute cardiac or medical condition, you really want someone trained to examine them behind it, and have the capability to monitor more than one lead - and if you have chest pain, syncope, or breathing problems, you probibly want the capability to run serial 12-leads.

/a clean 12-lead doesn't mean you're not having a heart attack. It only means you're not having a heart attack that will kill you in the next 90 minutes.

hardinparamedic:Yeah, but it's lead II vector monitoring. Which is only good for monitoring arrythmias. As Bob Paige says in his EKG seminars - Lead II no Clue.

In addition, beyond looking for the kind of arrythmias that you won't be able to look at your phone to see, it's a fun novelty but useless clinically.

If you need an ECG for an acute cardiac or medical condition, you really want someone trained to examine them behind it, and have the capability to monitor more than one lead - and if you have chest pain, syncope, or breathing problems, you probibly want the capability to run serial 12-leads.

/a clean 12-lead doesn't mean you're not having a heart attack. It only means you're not having a heart attack that will kill you in the next 90 minutes.

No leg lead, only hand to hand, so a sketchy Lead I. If they added a lead for right and left leg, at least they'd have Einthoven's triangle and slightly more useful diagnostic tool. Since the patient would be holding the phone probably at waist level, the wires could easily be less than 3 feet and attached on the stomach for minimal inconvenience.

Fun Dumpster:No leg lead, only hand to hand, so a sketchy Lead I. If they added a lead for right and left leg, at least they'd have Einthoven's triangle and slightly more useful diagnostic tool. Since the patient would be holding the phone probably at waist level, the wires could easily be less than 3 feet and attached on the stomach for minimal inconvenience.

hardinparamedic:Fun Dumpster: No leg lead, only hand to hand, so a sketchy Lead I. If they added a lead for right and left leg, at least they'd have Einthoven's triangle and slightly more useful diagnostic tool. Since the patient would be holding the phone probably at waist level, the wires could easily be less than 3 feet and attached on the stomach for minimal inconvenience.

Palm had an app for EKG's also (going back to the palm III series). This is nothing new, someone just finally ported it to Iphone. The difference was the palm app had full 12 lead cables that hooked up to the palm.

hardinparamedic:Fun Dumpster: No leg lead, only hand to hand, so a sketchy Lead I. If they added a lead for right and left leg, at least they'd have Einthoven's triangle and slightly more useful diagnostic tool. Since the patient would be holding the phone probably at waist level, the wires could easily be less than 3 feet and attached on the stomach for minimal inconvenience.

Yep. You're right. It's lead 1. I stand corrected on that.

JPINFV:hardinparamedic: Fun Dumpster: No leg lead, only hand to hand, so a sketchy Lead I. If they added a lead for right and left leg, at least they'd have Einthoven's triangle and slightly more useful diagnostic tool. Since the patient would be holding the phone probably at waist level, the wires could easily be less than 3 feet and attached on the stomach for minimal inconvenience.

Yep. You're right. It's lead 1. I stand corrected on that.

If it makes you feel better, I made the same mistake.

/supposed to be above stupid mistakes like that.

No biggie. It would make more sense to run Lead II off the app, since the majority of ECG machines seem to run it at the bottom of a 12 lead strip.

thelunatick:Palm had an app for EKG's also (going back to the palm III series). This is nothing new, someone just finally ported it to Iphone. The difference was the palm app had full 12 lead cables that hooked up to the palm.

The problem with it is that the computer is a lying bastard. The algorhythms that they use to interpret require precise conditions to be accurate, and that is not always possible. Placement can be off. The patient can have muscle tremor or other artifact. STEMI mimics, like pericarditis, and hyperkalemia can confuse the algorhythm and tempt you to make a trip to the cath lab.

Just to coin an example, the 12SL algorythm, which Phillips and Zoll use, was infamous for calling muscle tremors atrial flutter, and would pick up early repolarization as a STEMI for a while. Physio-Control uses the Glasgow rhythm algorythm, which is still useful, but placement is key. There's now a push to make 15-lead and 18-lead EKGs the standard because of missed inferior-posterior AMIs.

There's a reason we read the EKGs and transmit them to the ERs, and there's a reason a physician has to read them before a decision is made.

hardinparamedic:thelunatick: Palm had an app for EKG's also (going back to the palm III series). This is nothing new, someone just finally ported it to Iphone. The difference was the palm app had full 12 lead cables that hooked up to the palm.

The problem with it is that the computer is a lying bastard. The algorhythms that they use to interpret require precise conditions to be accurate, and that is not always possible. Placement can be off. The patient can have muscle tremor or other artifact. STEMI mimics, like pericarditis, and hyperkalemia can confuse the algorhythm and tempt you to make a trip to the cath lab.

Just to coin an example, the 12SL algorythm, which Phillips and Zoll use, was infamous for calling muscle tremors atrial flutter, and would pick up early repolarization as a STEMI for a while. Physio-Control uses the Glasgow rhythm algorythm, which is still useful, but placement is key. There's now a push to make 15-lead and 18-lead EKGs the standard because of missed inferior-posterior AMIs.

There's a reason we read the EKGs and transmit them to the ERs, and there's a reason a physician has to read them before a decision is made.

Definitely This. I see GEs and HPs call any kind of tremor/artifact "Probable lateral/septal infarct" and/or afib all the time. The algorithms are only a very loose guide.

hardinparamedic:Yeah, but it's lead II vector monitoring. Which is only good for monitoring arrythmias. As Bob Paige says in his EKG seminars - Lead II no Clue.

In addition, beyond looking for the kind of arrythmias that you won't be able to look at your phone to see, it's a fun novelty but useless clinically.

If you need an ECG for an acute cardiac or medical condition, you really want someone trained to examine them behind it, and have the capability to monitor more than one lead - and if you have chest pain, syncope, or breathing problems, you probibly want the capability to run serial 12-leads.

/a clean 12-lead doesn't mean you're not having a heart attack. It only means you're not having a heart attack that will kill you in the next 90 minutes.

True... BUT.... It would seriously make my medication cheaper.

/My psych had a patient on stimulants for ADHD go into cardiac arrest during a panic attack in her office. Now ALL patients on stimulants MUST PAY for quarterly EKGs or NO MEDS for you!

I bet this would be enough "reasonable precaution" to get her to back off sucking $500 a quarter out of her patients wallets.

The diagnosis details are covered up thread, however, for research purposes, this might be a great way to do some quick/easy ECG recording in the lab. We only ever use a basic lead 2 setup to get IBI data (for HRV analysis). This could result in some potential for undergraduate research projects where you record at various phases as long as the tasks do not involve one of the hands.

DON.MAC:I wonder if this is a more useful solution than the old "you are not having a heart attack, stop wasting my time because if we check you out again, we will get the same results we had last week"

Lead I can tip you off that you're having a Lateral STEMI, and can show reciprocal inferior changes, but you need a 12-lead to identify. ST-Elevation in a single lead is non-diagnostic, except for specific criteria in the Pre-cordial leads and Augmented Vector leads.

In addition, you can be having a heart attack and not have EKG changes. They're great for identifying the ones that are going to kill you quickly, but not for the ones that are going to kill you over the next week and don't require an immediate trip to the cath lab to fix.

I'm pretty sure it's more a question of liability as to why stuff like this hasn't been more widely adopted.

The actual circuitry for an EKG is pretty simple. Correct me if I'm wrong, but with a little filtering the loudest signal from arm to arm in a resting human body is the heart, and you feed that into an instrumentation amp with the leg as a "neutral" center point. Boost that to a 3-5V signal, and any decent sound processor (like the sound card on a PC or the headset on a phone) can handle both the meaningful bandwidth and resolution of the signal. The parts involved are maybe $40 at Jameco, a decent EE who's careful about grounding and shielding can deliver the data.

The data capture is nothing. The interpretation is the rocket science.

There is another factor though. Damn near every data sheet for an electronic part that I have seen in 30 years of experience has a disclaimer like this towards the end:

"Motorola products are not designed, intended, or authorized for use as components in systems intended for surgical implant into the body, or other applications intended to support or sustain life, or for any other application in which the failure of the Motorola product could create a situation where personal injury or death may occur"

or

"NATIONAL'S PRODUCTS ARE NOT AUTHORIZED FOR USE AS CRITICAL COMPONENTS IN LIFE SUPPORT DEVICES OR SYSTEMS WITHOUT THE EXPRESS WRITTEN APPROVAL OF THE PRESIDENT OF NATIONAL SEMICONDUCTOR CORPORATION. As used herein:1. Life support devices or systems are devices or 2. A critical component is any component of a lifesystems which, (a) are intended for surgical implant support device or system whose failure to perform caninto the body, or (b) support or sustain life, and whose be reasonably expected to cause the failure of the lifefailure to perform, when properly used in accordance support device or system, or to affect its safety orwith instructions for use provided in the labeling, can effectiveness be reasonably expected to result in a significant injury to the user."

Emphasis mine.

IANAL, but I don't doubt that someone who was could make the case that ANY medical monitoring device could fit that. I have no idea how insulin monitors ever took off.

maxheck:The data capture is nothing. The interpretation is the rocket science.

Actually, the data capture is a huge issue. One lead is a very very small picture of the heart. Unless it's a rhythm problem (and a lot of heart issues that show up on an EKG aren't rhythm problems), you can't really really diagnose anything. There's a much larger picture that you end up missing.

maxheck:IANAL, but I don't doubt that someone who was could make the case that ANY medical monitoring device could fit that. I have no idea how insulin monitors ever took off.

What JPINFV said, but things like blood glucose monitors are special cases. The corporations that sell them to the public had to have them approved as OTC Medical Devices by the FDA - namely that any level of medical expertise was not necessary to use them. Even then, there are versions of them that are not sold to the general public, and include advanced monitoring features for healthcare.

A One Touch you buy in Walgreens is not similar to an iSTAT monitoring system used by a critical care team.

There's a reason that all the AEDs that are sold to the general public do not have EKG monitoring capabilities, besides they added cost to the manufacturer.

maxheck:There is another factor though. Damn near every data sheet for an electronic part that I have seen in 30 years of experience has a disclaimer like this towards the end:

Electronics used in mission-critical components, like defibrillators, insulin pumps, IV pumps, and ventilators, have to be tested extensively before they are allowed to be used. It's the reason that these machines have extensive self-check circuits built in to identify failures before they're used on a patient. In addition, the end product has to be FDA approved before it can be used on another human being.

Ironically, the ventilators we use in our hospital have Windows Embedded as the operating system they run.

maxheck: The data capture is nothing. The interpretation is the rocket science.

Actually, the data capture is a huge issue. One lead is a very very small picture of the heart. Unless it's a rhythm problem (and a lot of heart issues that show up on an EKG aren't rhythm problems), you can't really really diagnose anything. There's a much larger picture that you end up missing.

Let me correct myself...

From an EE standpoint, collecting the data with the useful but incomplete three-lead design I vaguely designed, it's trivial. Designing a circuit even for the 12-lead design used in a full workup isn't chainsaw juggling either. Stupid circuits filtering and amplifying signals.

This is not to say it can't be screwed up, of course, but...

Recording and storing those signals is also easy with modern devices.

Processing those signals is the hard part. I've heard a lot of complaints in this thread that some of the (I'm assuming very expensive) real-time systems made by large companies have problems with that part.

However, and this makes me somewhat hopeful... No matter how flawed the processing on your particular phone app might be, you can always send a raw data dump to someone else.

Would a system like this replace a full workup with a well-trained tech? Of course not. It's never going to obviate the need for an EKG under better-controlled conditions. I'd think having patients place the electrodes would be a major source of error if nothing else.

But... IF someone is at-risk, this might be a useful, less-obtrusive and cheaper way for them to be monitored than having them visit a clinic every week / month / whatever.

maxheck: IANAL, but I don't doubt that someone who was could make the case that ANY medical monitoring device could fit that. I have no idea how insulin monitors ever took off.

What JPINFV said, but things like blood glucose monitors are special cases. The corporations that sell them to the public had to have them approved as OTC Medical Devices by the FDA - namely that any level of medical expertise was not necessary to use them. Even then, there are versions of them that are not sold to the general public, and include advanced monitoring features for healthcare.

A One Touch you buy in Walgreens is not similar to an iSTAT monitoring system used by a critical care team.

There's a reason that all the AEDs that are sold to the general public do not have EKG monitoring capabilities, besides they added cost to the manufacturer.

maxheck: There is another factor though. Damn near every data sheet for an electronic part that I have seen in 30 years of experience has a disclaimer like this towards the end:

Electronics used in mission-critical components, like defibrillators, insulin pumps, IV pumps, and ventilators, have to be tested extensively before they are allowed to be used. It's the reason that these machines have extensive self-check circuits built in to identify failures before they're used on a patient. In addition, the end product has to be FDA approved before it can be used on another human being.

Ironically, the ventilators we use in our hospital have Windows Embedded as the operating system they run.

Thanks for an informative post!

What always amused me is that there's never any disclaimer like "We assume no responsibility if your nuclear weapons control system fails," or "we 're not responsible if your aircraft falls out of the sky," but they invariably have that medical disclaimer.

I understand that it's a different testing regime though, and of course the US DOD requires parts to be run through stress tests *even if the parts have been sitting on the shelf,* or at least they did during the Reagan era.

Also, thank you Fun Dumpster for the term "Einthoven's triangle" From an electrical standpoint and with 100 years of hindsight I knew it had to be there, I just had no idea what it was called.

hardinparamedic:thelunatick: Palm had an app for EKG's also (going back to the palm III series). This is nothing new, someone just finally ported it to Iphone. The difference was the palm app had full 12 lead cables that hooked up to the palm.

The problem with it is that the computer is a lying bastard. The algorhythms that they use to interpret require precise conditions to be accurate, and that is not always possible. Placement can be off. The patient can have muscle tremor or other artifact. STEMI mimics, like pericarditis, and hyperkalemia can confuse the algorhythm and tempt you to make a trip to the cath lab.

Just to coin an example, the 12SL algorythm, which Phillips and Zoll use, was infamous for calling muscle tremors atrial flutter, and would pick up early repolarization as a STEMI for a while. Physio-Control uses the Glasgow rhythm algorythm, which is still useful, but placement is key. There's now a push to make 15-lead and 18-lead EKGs the standard because of missed inferior-posterior AMIs.

There's a reason we read the EKGs and transmit them to the ERs, and there's a reason a physician has to read them before a decision is made.

Just pointing out it's nothing new. And don't know what EMS system you work for but in the one I work in we don't need to transmit. We are taught to interpret them ourselves.

thelunatick:Just pointing out it's nothing new. And don't know what EMS system you work for but in the one I work in we don't need to transmit. We are taught to interpret them ourselves.

Oh, no. We're taught to interpret here, we just can't make the final cath lab decision without going through cardiology, and State Medical director wants us to transmit if we're greater than 30 minutes out so they can make that decision.